Borderline Patrol

After returning from vacation I made it my business to get serious about my mental health coursework and take my continuing education courses to renew my license, which is up next March. It has been almost two years since I closed my practice, and while I come out of the bullpen from time to time for personal or institutional requests or workshops, more of my attention has been focused on theology—teaching for my diocese, blogging, and the like. But I do miss the regular interactions of psychotherapy and the science behind it, so it’s back to internet school, and I guess you are coming along with me whether you want to or not.
 
Somewhere in my recent reading on moral theology I came across a quote to this effect, “It is not enough to worry about your sins; you should worry about your attitude toward your sins.” True enough, but whenever one moves in the direction of this kind of introspective, mental health development—or the lack thereof—comes into play. The directions of our thoughts and behaviors—the heart of our spiritual life—is integrated into our brain function in ways we do not fully understand but must acknowledge. While Catholicism has never literally embraced the twentieth century theories of Sigmund Freud, its monastic mentors were counseling novices to avoid excessively rigorous penitential practices fifteen centuries ago and in 2016 the Church screens candidates for the priesthood for sound mental states of mind. (How seriously individual bishops weigh input from competent psychologists is hard to say, though.)
 
There are a significant numbers of good reasons for church ministers to be well versed in foundational principles of mental health and disorders, the first being that habitual self-care of one’s own state of mind is a sine qua non of professional satisfaction—lucky the parish, for example, to be led by a priest who is at peace with himself and enriched by his healthy encounters with his flock. A second reason is the assessment of volunteers and professional hires for suitability for specific ministerial placements. Introverts are not always comfortable undertaking major fundraising—a lesson I learned myself the hard way.
 
A third reason—and perhaps the most critically demanding—is damage control. I was reminded of this on Monday afternoon while reading Borderline Personality Disorder: The Latest Assessment and Treatment Strategies by Melanie Dean, Ph.D. (2006), for an online course of the same name. I reflected back to my practice days and I had to admit that my therapeutic encounters with such individuals were tense. BPD individuals are prone to statistically high suicide and self-harming episodes; they can be seductive in every sense of the word, unpredictable, and notoriously resistant to discipline or organized office treatment schemas. They can become immediately hostile if they sense any clue of rejection (such as a therapist’s taking notes instead of looking them in the eye.) I found it interesting that some of the Amazon reviewers gave poor ratings to the book because the author reported the sad fact that BPD individuals do not generally respond to our current available psychotropic or mental health medications. (I have a Wikipedia link here, slightly outdated, which is a fair description of personality disorders in general.)
 
Given that personality disorders in general are not controllable with medication—unlike “mood disorders” such as depression, anxiety, bipolar, etc.—it is also true that many of the arrows in our pastoral quivers are equally ineffective. Spiritual advice, confession, and kind listening, for example, can actually make the situation worse for an unwary minister and the troubled soul. Personality disorders such as the borderline type are, at the end of the day, diseases of thought, unlike depression which probably has organic roots. PD’s are consistent and enduring, unlike mood disorders which are “transient” and clinically proven to respond to a combination of medication and psychotherapy in most cases.
 
Here is a not-uncommon parish scenario. Many people approach the church for counsel, advice, or spiritual direction, most often seeking the priest. Given that about one in 50 Americans suffer some form of BPD, and the majority of cases are women, an individual seeking comfort because of an unhappy marriage or general loneliness may quickly attach to the priest, long before he catches on to the level of intensity of the counselee’s attachment. While there may be a sexual element here, the root cause of BPD is fear of abandonment and isolation, probably originating in the formative years when parents were emotionally unavailable or the counselee was abused by a parent in youth. (Dean, 19)
 
Thus, when a priest or minister attempts to set boundaries, such as less frequent appointments, refusal of gifts, or particularly referral, the counselee—whose whole conscious life has been a tale of rejection and separation—will usually react strongly, and it is the unpredictability of the reaction that makes BPD so dangerous for all involved. The risk of suicide is particularly high in this population. Certainly in my years as a priest I rarely thought to undertake a simple suicide assessment during my first pastoral counseling meetings, but the fact is that a previous attempt is a very good predictor of another, and we are wise to do some very basic screenings in church counseling—for substance use, for example, or history of child abuse. Such data is a flag that at least some of the counselee’s healing will need to involve a medical component (i.e. professional mental health personnel.)
 
A suicide of a patient or counselee is particularly difficult for church personnel, for our instincts, and some of our less informed training, leads us to take on more responsibility for individuals than is professionally wise. I suspect there may be legal risks here, too, particularly if the church counseling relationship has been prolonged for several years. A lawyer can make a good case that a church minister was essentially practicing medicine without a license and failed to take note of the counselee’s risk of self-harm. Suicide is not the only, nor even the most common, negative outcome in BPD individuals who perceive rejection, rightly or wrongly. Binge eating or drinking, binge shopping, promiscuity and self-mutilation are also common. Stalking is not unheard of. I hope to research the legal responsibilities further for future posts.
 
It is entirely possible—though statistically unlikely—that you will progress through your catechetical or ministerial life without a difficult encounter with personality-disordered individuals. I have focused on one type today, but in fact you are more likely to encounter histrionics or narcissists, the two types I have seen over the years on parish staffs or positions of church responsibility, and how unschooled parish workers have labored mightily and fruitlessly to accommodate them. After I take my on-line exam this week, I will look more closely at your more likely crosses to bear.